CANDIDATE GUIDE

PELVIC TRAUMA

I. Ask the candidate what is the most likely problem of this patient by looking at the clinical picture
- pelvic fractures
- hemodynamic instability

II. Ask the candidate definition and the etiology of pelvic trauma
 Definition: the fracture that happens to pelvic ring, which is a close compartment of bones
containing urogenital organs, rectum, vessels and nerves.
 Etiology: Patients with pelvic fractures are usually young and they have a high overall injury
severity score (ISS) (25 to 48 ISS)

III. Ask the candidate pathophysiology of pelvic trauma

 The lesions at the level of the pelvic ring can create instability of the ring itself and a consequent
increase in the internal volume.
 This increase in volume, particular in open book lesions, associated to the soft tissue and
vascular disruption  the increasing hemorrhage in the retroperitoneal space by reducing the
tamponing effect (pelvic ring can contain up to a few liters of blood) and can cause an alteration in
hemodynamic status.

 Classification

GRADE system to evaluate the level of evidence and recommendation

 WSES pelvic injuries classification

IV. Ask the candidate the diagnosis of pelvic trauma

Recommendations for diagnostic tools use in Pelvic Trauma

- The time between arrival in the Emergency Department and definitive bleeding control should be
minimized to improve outcomes of patients with hemodynamically unstable pelvic fractures [Grade
2A].
- Serum lactate and base deficit represent sensitive diagnostic markers to estimate the extent of
traumatic-haemorrhagic shock, and to monitor response to resuscitation [Grade 1B].
- The use of Pelvic X-ray and E-FAST in the Emergency Department is recommended in hemodynamic
and mechanic unstable patients with pelvic trauma and allows to identify the injuries that require an
early pelvic stabilization, an early angiography, and a rapid reductive maneuver, as well as laparotomy
[Grade 1B].
- Patients with pelvic trauma associated to hemodynamic normality or stability should undergo further
diagnostic workup with multi phasic CT-scan with intravenous contrast to exclude pelvic hemorrhage
[Grade 1B].
- CT-scan with 3-Dimensional bones reconstructions reduces the tissue damage during invasive
procedures, the risk of neurological disorders after surgical fixation, operative time, and irradiation and
the required expertise [Grade 1B].
- Retrograde urethrogram or/and urethrocystogram with contrast CT-scan is recommended in presence
 of local perineal clinical hematoma and pelvic disruption at Pelvic X-ray [Grade 1B].
- Perineal and a rectal digital examination are mandatory in case of high suspicious of rectal injuries
[Grade 1B].
- In case of a positive rectal examination, proctoscopy is recommended [Grade 1C].
- Sensitive laboratory markers of acute traumatic hemorrhage include serum lactate and base deficit by
arterial blood gas analysis
- the presence of coagulopathy should be determined early by “point-of-care“ bedside testing using
Thromboelastography (TEG) or Rotational Thromboelastometry (ROTEM), which allow targeted
resuscitation with blood products and improved post-injury survival rates
- Lelly maneuver can be useful in evaluating the pelvic ring stability but it should be done cautiously
because it can sometime increase the bleeding by dislocating bones margin.
- Chest X-rays and E-FAST are performed to exclude others sours of hemorrhage in the thorax and in
the abdomen

VI. Ask the candidate the operative management for this case (pelvic trauma)

Indication for definitive surgical fixation of pelvic ring injuries

- Posterior pelvic ring instability represents a surgical indication for anatomic fracture reduction and
stable internal fixation. Typical injury patterns requiring surgical fixation include rotationally unstable
(APCII, LC-II) and/or vertically unstable pelvic ring disruptions (APC-III, LC-III, VS, CM) [Grade 2A].
- Selected lateral compression patterns with rotational instability (LC-II, L-III) benefit from adjunctive,
temporary external fixation, in conjunction to posterior pelvic ring fixation [Grade 2A].
 - Pubic symphysis plating represents the modality of choice for anterior fixation of “open book” injuries
with a pubic symphysis diastasis > 2.5 cm (APC-II, APC-III) [Grade 1A].
- The technical modality of posterior pelvic ring fixation remains a topic of debate, and individual
decision-making is largely guided by surgeons’ preference. Spinopelvic fixation has the benefit of
immediate weight bearing in patients with vertically unstable sacral fractures [Grade 2C].
- Patients hemodynamically stable and mechanically unstable with no other lesions requiring treatment
and with a negative CT-scan can proceed directly to definitive mechanical stabilization [Grade 2B]

External fixation
- typically used to stabilize the bony pelvis and affects an approximate reduction of the bone
fragments
- Occasionally, the external fixator is used for definitive fixation, and in these cases, it is often left in
place for 8–12 weeks.
- External fixator pins are placed into the anterior ring, and given the long lever arm between the
posterior ring and the anterior frame, there is little ability to directly control the posterior pelvic ring.
- In these situations, the use of a “C-clamp” is advantageous.
- This device involves the placement of two pins, one through the outer table of each ilium, in the area
of the sacroiliac joint.
- The pins are then used to directly manipulate the fractured fragments, and an external frame is then
constructed to maintain this reduction.
- Pins can be safely placed into the iliac crest without the aide of C-arm fluoroscopy.
- Supra-acetabular pin placement is also useful, although this technique requires the use of C-arm
fluoroscopy to ensure safe pin placement
- An external frame then allows direct compression across the posterior aspect of the pelvis

Fig. External fixation involves the placement of pins into the innominate bones (a). In this case, the pins
are placed into the iliac crest (b). An anterior frame is then constructed to maintain the reduction of the
pelvis. This frame can be adjusted to allow for access to the abdomen if required. External fixation
provides the excellent control of anterior displacement but does not allow for reduction or stabilization of
injuries that involve significant posterior displacement
 Fig. The C-clamp is useful in controlling fractures with significant posterior displacement (a). In this
case, specialized pins (b) are placed at the level of the sacroiliac (SI) joint, and direct manipulation and
compression of the posterior pelvis is possible
Ideal time-window to proceed with definitive internal pelvic fixation
- Hemodynamically unstable patients and coagulopathic patients “in extremis” should be successfully
resuscitated prior to proceeding with definitive pelvic fracture fixation [Grade 1B].
- Hemodynamically stable patients and “borderline” patients can be safely managed by early definitive
pelvic fracture fixation within 24 h post injury [Grade 2A].
- Definitive pelvic fracture fixation should be postponed until after day 4 post injury in physiologically
deranged politrauma patients [Grade 2A].

● Postoperative Management
o Postoperative CT is recommended to assess pelvic ring reduction and implant safety,
particularly when iliosacral screws are used.
o Long-acting oral narcotic medications may be useful as an adjunct to PCA to provide sustained
pain control
o DVT prophylaxis is important postoperatively and should be managed aggressively.
o Patients are mobilized according to their particular injury pattern, with a goal of full
weightbearing by 3 months postoperatively.
o After discharge from the hospital, patients are seen in follow-up 2 weeks postoperatively for a
wound check.
o They are seen again 6 weeks postoperatively for repeat clinical and radiographic examination.
o Further postoperative visits are scheduled at 3, 6, and 12 months postoperatively.

1. Coccolini, F., Stahel, P.F., Montori, G. et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg 12, 5 (2017).
https://doi.org/10.1186/s13017-017-0117-6
2. Lee C, Sciadini M. The Use of External Fixation for the Management of the Unstable Anterior Pelvic Ring. J Orthop Trauma. 2018
Sep. 32 Suppl 6:S14-S17. [Medline].
3. Weaver, M.J., Heng, M. Orthopedic Approach to the Early Management of Pelvic Injuries. Curr Trauma Rep 1, 16–25 (2015).
https://doi.org/10.1007/s40719-014-0005-4